Financial Needs Analysis Questionnaire
Expert Financial Analysis
Confidential Questionnaire
Print client names
First Name (client 1)
MI
Last Name
Birth Date
Social Insurance #
Sex
Drivers License #
Issue Date
Expiration Date
Birth Place
First Name (client 2)
MI
Last Name
Birth Date
Social Insurance #
Sex
Drivers License #
Issue Date
Expiration Date
Birth Place
Print children's names (if applicable)
Last
First
Last
First
Last
First
Last
First
* Relationship to the Client: (son, daughter, stepchild, etc.)
Mailing address and contact info
Address
MI MI MI MI
City
Sex
M F
Sex
M F
Sex
M F
Sex
M F
Relationship* Relationship* Relationship* Relationship*
Province
Postal Code
Birth Date Birth Date Birth Date Birth Date
Years at Address
Home Phone
( )
E-mail Client 1
Client 1 Work
( )
Client 2 Cell
( )
Email Client 2
Client 2 Work
( )
Client 2 Cell
( )
Enter client 1's employer (If less than 2 years, please include prior employer)
Name of Employer
Date Hired
Occupation
Address
City
Province
Postal Code
Enter client 2's employer (If less than 2 years, please include prior employer)
Name of Employer
Date Hired
Occupation
Address
City
Province
Postal Code
Previous Employers (If necessary)
Name of Company
Name of Company
Time Employed Time Employed
1..INCOME SOURCES
)
Income (pay-stub?):
Other Monthly Income:
$__________________ $__________________
$__________________ $__________________
How often are you paid?
____ Weekly ____ 2x/month ____ Biweekly ____ Monthly
Monthly Income Taxes: $__________________ $__________________
Do you normally receive an income tax refund? Yes No How much was your last tax refund? $___________________
Filename: 2014 EFA data Collection Sheet
Page 1
Revised: 2/2/2015
2. EMPLOYER SPONSORED RETIREMENT PLANS Are you currently involved in any type of retirement plan through work?
Current Total Balance
Yes No ___________
$__________
Yes No ___________
$__________
How much do you contribute monthly? Does your employer match your retirement contributions?
$__________ Yes No
$__________ Yes No
How much? $________ _____%
At What age would you like to Retire?
__________
$________ _____% __________
How much monthly income would you like to receive at retirement in today's dollars? $__________ _____% (i.e. $ or 80% of current income) Is retiring well important enough that you would commit to setting aside money every month? Yes No If I can help you retire at age _________, would you implement that plan? Yes No
3. OTHER RETIREMENT ASSETS
Do you have any other funds for retirement? (RRSP's, TFSA's or Retirement Plans from Previous Employer)
Client 1
What are the balances in these accounts? $___________
Yes No
Client 2
$___________
Monthly Contribution $___________ If we could show you a better solution for these accounts, would you be willing to move them? Yes No
$___________
4. OTHER ASSETS Do you have any other assets (real estate, jewelry, etc.)
Yes No If yes, what is the value? $__________________
______________________________________________________________________________________________________________________
5. NON-RETIREMENT ASSETS
Client 1 Balance
Client 2 Balance
Total Balance
Monthly Contributions
Bank Savings, Checking $__________
$__________
$__________
$__________
Stocks, Mutual Funds CD's, Bonds $__________
$__________
$__________
$__________
6. PROTECTION INFORMATION
Do you have a current will? Yes No If it were affordable, would you like to have one? Yes No
Other Insurance Payments Auto $__________ Health $__________ Dental $__________ Home $__________ Other $__________ Would you like to see if you could save Money on your car insurance? Yes No
Life Insurance Coverage
Do you use tobacco in any form? Is there any reason either of you would not qualify for Life Insurance? (Medical History)
Do you have any Life Insurance coverage at work? Group Coverage Amount Paid For By Employer Amount of Employee paid coverage
Client 1
Yes No Yes No Yes No $__________ $__________
Client 2
Yes No Yes No Yes No $__________ $__________
Children
Yes No
$__________ $__________
How much of the premium do you pay per month?
$__________
$__________
$__________
What happens to your group coverage if or when you leave your employer? __________ (generally, this is lost if you leave due to layoff or extended illness)
Filename: 2014 EFA data Collection Sheet
Page 2
Revised: 2/2/2015
Do you own personal life insurance other than through work? Yes No
IF NO: When people do not have life Insurance it is usually for a couple different reasons.
Did not see the need
Could not afford it
Never got around to it Other _____________________
IF YES: Do you feel that you are over-insured or underinsured, right now? Over-insured Under-insured Don't Know
What type of policy do you currently have? What is the face Amount?
What are your current monthly premiums? When did you buy it?
Why did you buy your existing plans? Protection Savings Both
Client 1
__________ $__________ $__________
__________
Client 2
__________ $__________ $__________
__________
Children
__________ $__________ $__________
__________
If you were to consider a change in benefits, what interests you most? Lower cost More protection More savings (check all that apply)
When was the last time you spoke with the agent who sold you this insurance policy? __________________________
If you were to die prematurely do you want your....
Debt paid off? Mortgage paid off? Children's education Paid? Funeral & final expenses paid?
Client 1 Yes No Yes No Yes No Yes No
Client 2 Yes No Yes No Yes No Yes No
If all of these were paid off how much monthly income would your survivors need? For how many years?
$_____________ per mo. $____________per mo. ______________years _____________ years
(If they have protection) If we put together a plan that improves your current plan, would you change if it were better?
Yes No
(If NO protection) If we put together a plan that will protect your family and it is within you budget, would you get the protection? Yes No
Are you be interested in Disability, Health and Dental, or Critical Illness Insurance Coverage? ___________________________________
______________________________________________________________________________________________________________________
7. EDUCATION DATA
Child 1
Education Cost
__________
Percentage You Intend to Pay __________%
Current Savings Balance $__________
Current Monthly Contributions $__________
Child 2
__________ __________% $__________ $__________
Child 3
__________ __________% $__________ $__________
Child 4
__________ __________% $__________ $__________
Child 5
__________ __________% $__________ $__________
Child 6
__________ __________% $__________ $__________
8. OTHER GOALS AND DREAMS Are there any major purchases that you are looking to make in the next 3-5 years? (new home, car, vacation, etc.) __________________________ ______________________________________________________________________________________________________________________ 9. MORTGAGE DATA Original Purchase Price: $__________________ Current Mortgage Balance: $__________________ Interest Rate : ________% When did you buy your home? __________ Amount of Down Payment?: $___________ How much could you sell your home for? $___________
Payment Details:
Principal & Interest Payment: Monthly Property Taxes:
Mortgage Insurance Premium Total Monthly Mortgage Payment:
$__________ (Monthly, Weekly, Biweekly) $__________ Mortgage Company: ________________________________ $__________ Renewal date:_____________________________________ $__________ *Please fill out Zero Plan forms for smoother processing
Filename: 2014 EFA data Collection Sheet
Page 3
Revised: 2/2/2015
______________________________________________________________________________________________________________________ 10. CONSUMER DEBT Do you have any debt outside your mortgage? Yes No
Debt
Balance
Min. Payment.
Actual Payment. Insurance Premium
Interest Rate
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________ ________%
_______________________
$____________ $__________ $__________ $__________
________%
_______________________
$____________ $__________ $__________ $__________
________%
NOTE: If car is leased, do not list as a debt ? unless planning to purchase outright.
What I'd like to do now is explore all of the possibilities to get you debt free and see which debt elimination plan is best suited for your family. That might be a debt consolidation loan through refinancing, or possibly Debt Snowball. Get authorizations on the Zero Plan application to see if we can help.
______________________________________________________________________________________________________________________
11. Experts say we should budget 10% of our monthly gross income for financial and retirement planning. 10% of your monthly income is $________
Is this an amount that you could feel comfortable setting aside each month. Yes No If no, how much of the 10% would you feel
comfortable with on a monthly basis. $100 per month $200 per month $500 per month Other $_________________
12. COMMITMENTS If when I come back and I offer you a program that could improve upon your current savings, debt situation, or insurance needs, will you implement and follow that program if it is better for you? Yes No
Last but not least, my `fee for service' is referrals and recommendations. Will you provide me with a minimum of 5 referrals if you like what I can implement for you? Yes No (Leave Referral Sheets)
EFA Follow-up Date: ______________________
Time: ______________
I/We have been advised that the Experior Financial Group Advisor is not a mortgage broker/agent and they have not discussed mortgages, or interest rates.
I authorize my representative and insurer and its authorized personnel to use the personal information contained in this document to review my financial needs on a regular basis and make appropriate recommendations. I authorize my Experior Financial Group representative to share all the above with any affiliated company required to develop and complete a comprehensive financial analysis of my situation including recommendations. The personal information you have provided in this document for the purpose of analyzing your financial needs will remain confidential. Only your representative, insurer and their authorized personnel will have access to the information in your file. Unless required by law it will be disclosed only to persons duly authorized by you. You are entitled to consult the personal information contained in this file and, if applicable, have it corrected by sending us a written request. I/We understand that Experior Financial Group may receive a referral fee from the lending institution.
Approved By: _____________________________________________________________ Approved By: _____________________________________________________________
Date: _________________________ Date: _________________________
Filename: 2014 EFA data Collection Sheet
Page 4
Revised: 2/2/2015
The greatest compliment you can give is referrals.
Client's Name: _________________ Agent's Name: _________________
WHO DO YOU KNOW?
BEST FRIEND
FAMILY
CO-WORKERS
___________________________________________________________________________________________________________________________________________________
1)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
2)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
3)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
4)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
5)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
6)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
7)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
8)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
9)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
10)
Name(s):_____________________________________________ Phone #__________________________________ Relationship________________________________
Occupation: __________________________ Age 25-55
Married
Children
Homeowner
Employed
____________________________________________________________________________________________________________________________________________________
Filename: 2014 EFA data Collection Sheet
Page 5
Revised: 2/2/2015
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